[CT and histological findings and treatment outcomes after carotid endarterectomy for symptomatic cervical carotid artery stenosis in octogenarians]

Symptomatic cervical carotid artery stenosis is one of the common causes of ischemic stroke in octogenarians. The records for 90 consecutive patients with symptomatic cervical carotid artery stenosis treated by carotid endarterectomy(CEA)were analyzed retrospectively. The patients were divided into two groups:21 patients aged 80 years or over and 69 patients aged less than 80 years. CT angiography revealed that ulcer formation was significantly more common and the length of carotid artery stenosis was significantly greater in the octogenarians. Histological examination of the plaque revealed no significant difference between the two groups in terms of ulcer formation, lipid content, and intraplaque hemorrhage. However, all three of these pathological findings were present in a significantly higher number of octogenarians. No significant difference was observed for new ischemic lesions on diffusion-weighted MR imaging, neurological complications, or cardiac and pulmonary complications. However, treatment with an albumin preparation and loop diuretics was significantly more common in octogenarians after CEA. The present study suggests that with careful postoperative management CEA can be safely performed in symptomatic patients aged 80 years or over with almost the same risk as that for patients aged less than 80 years.

[Bilateral ptosis and upper gaze palsy with pupil sparing caused by midbrain hemorrhage]

The arrangement within the midbrain oculomotor nerve complex and crossed innervation of the superior rectus muscle are not elucidated in humans. A 65-year-old woman visited our hospital complaining of difficulty opening her eyes. Neurological examination revealed bilateral ptosis and impaired supraduction. The pupils prompty constricted to light. Results of CT and MRI demonstrated that there was a hematoma located in the dorsal midbrain tegmentum that spared the rostral mid-brain. It was presumed that the nerves of the superior rectus and levator palpebrae lie in the midbrain tegmentum more dorsally and medially than the others. Furthermore, crossed innervation of the superior rectus muscle can explain that lesions located in the dorsal midbrain tegmentum cause more often impaired supraduction.

[Regional pulmonary function in intra-emphysematous bulla and peri-emphysematous bulla]

We have measured regional alveolar volume and regional ventilation of emphysematous lesions and periemphysematous lesions with positron emission tomography and N-13 gas in 10 patients. The purpose of the study was to investigate how emphysematous lesion develops. The subjects were all male (except one) who put on a mask in supine position, and were connected with a spirometer. We gave N-13 gas in this closed circuit and had the gas rebreathed by the subjects. After activity reached equilibrium in closed circuit, an equilibrium scan was made. We took "activity gas" from the closed circuit and measured activity by well counter during equilibrium to get quantitative alveolar volume. The activity in closed circuit during equilibrium showed activity in the thoracic unit. After equilibrium, we used air to wash out radioactive gas from the circuit. During washout we took 3 sequential images. The decreased rate of activity in the region of interest from these 3 sequential washout images was expressed in a monoexponential curve. The index of monoexponential denotes V/V. Alveolar volume in emphysematous lesions was 34.8 +/- 19.5 ml/100ml thoracic volume, and V/V in these lesions was 0.27 +/- 0.21/min. On the other hand alveolar volume in periemphysematous lesions was 76.5 +/- 13.1 ml/100ml thoracic volume, and V/V was 0.38 +/- 0.22/min. Thus alveolar volume in periemphysematous lesions was relatively high. These results indicate that the effect of emphysematous lesions as compared with periemphysematous lesions was not direct compression of alveolar space. The direct effect was compression to the bronchiole of peripheral lesions, and check valve mechanism occurred in the bronchiole causing peripheral lesions resulting in the destruction of the alveolar wall.

[An approach to tuberculosis in newcomers from Asia and Africa]

In recent years, it has been documented that tuberculosis frequently occurs among recently entered foreigners dominantly from Asia. We studied 85 cases admitted to our hospital for active tuberculosis from 1986 to 1990. Many of those cases, we believe, were infected in countries of origin and were reactivated soon after or before entering Japan. In spite of higher rate of involving recurrent cases and resistance to anti-mycobacterial drug agents, chemotherapy has been generally efficient. In some cases, continuance of treatment was difficult because of their illegal stay, misunderstanding of the disease or other problems such as customs and economic difficulties.

[An approach to the control of the so-called vagrant patients with tuberculosis]

In recent 3 years, we experienced 46 cases of so-called vagrants, who were admitted for active tuberculosis to our hospital at the time of detection, their disease was in advanced and severe state, and 35 out of 46 patients were admitted for emergency and 7 cases died of tuberculosis soon after admission. In the remaining cases, anti-tuberculosis agents were effective, however, the incidence of dropout cases was much higher. How to improve compliance of these cases to treatment is one of the most difficult but important problem in present tuberculosis control.